Clostridium: Disease caused,

virulence factors, biochemical

reactions, gram staining
PRACTICAL
CLOSTRIDIUM
• Gram-positive bacilli, having bulging spores
• Saprophytes found in soil, fresh water, marine water, decaying
vegetation, animal matter and sewage
• Harbored in intestine of vertebrates and invertebrates
• Human Pathogens:
- C. perfringens: Gas gangrene
- C. tetani: Tetanus
- C. botulinum: Causes botulism
• C. difficile: Causes pseudomembranous colitis.
Spore of Clostridia
• Wider than the vegetative bacteria  swollen or spindle-shaped
appearance
• Most of the clostridia bear a sub-terminal spores except
- C.bifermentans – Central & oval
- C.perfringens – subterminal & oval
- C.tetani – terminal & spherical (drumstick)
- C.tertium – terminal & oval (tennis racket)
Cultivation
• Clostridia grow well in common anaerobic media
• Robertson’s cooked meat (RCM) broth
- Chopped meat particles  glutathione and unsaturated fatty acids
which take up oxygen
• Proteolytic - turn the meat black and produce foul odor, e.g. C. tetani,
C. botulinum A, B and F.
• Saccharolytic species - turn the meat pink, e.g. C. perfringens, C.
difficile and C. botulinum C, D and E.
 Robertson cooked meat broth: A. Uninoculated;
B. Pink and turbid (C. perfringens); C. Black and turbid (C. tetani)
C. perfringens
• C. perfringens (previously, C. welchii) - commensal in human animals
large intestine and environmental saprophyte
• Capsulated, non-motile, gram-positive bacillus
• Sub-terminal bulging spores, NO spores in tissues or in culture media
(especially the gas gangrene strains)
• Invasive and toxigenic.
Major Toxins of C.difficile
Toxin Biological activity
Alpha (α) Lethal, lecithinase (phospholipase C)
Hemolytic, Requires Ca+2 ion
Beta (β) Lethal, necrotizing, trypsin labile
Epsilon (ε) Lethal, permease, trypsin activatable
Iota (ι) Lethal, dermonecrotic,
Binary, has 2 fragments
 A-ADP ribosylating
 B- Binding
Alpha (α) Lethal, lecithinase (phospholipase C)
Hemolytic, Requires Ca+2 ion
Classification of C.perfringens
Type Major Toxin produced Disease
A Alpha Gas gangrene,
Food poisoning
B Alpha, beta and epsilon Lamb dysentery
C Alpha and beta Enteritis necroticans in
humans
D Alpha and epsilon Enterotoxemia and pulpy kidney
disease in sheep
E Alpha and iota Possible pathogen of sheep
and cattle
Clinical Manifestations
• Mostly polymicrobial involving other clostridia species
• Clostridial Wound Infection (MacLennan Classification)
• Simple wound contamination: wound surface contamination,
without invasion of underlying tissue, as occurs in absence of
devitalized tissue
• Anaerobic cellulitis: Involves fascial plane with minimal toxin release,
without muscle invasion
• Anaerobic myositis (gas gangrene): Muscle invasion occurs, which
leads to gas in the muscle compartment with abundant toxin release
Clostridial Enteric Infection
• Food poisoning: C. perfringens type A enterotoxin (
- Improperly cooked contaminated meat
- Diagnosis: By detection of enterotoxin in feces by enzyme
immunoassay
• Enteritis necroticans (gas gangrene of the bowel/ Bigbel/
Darmbrand): life-threatening condition - ischemic necrosis of the
jejunum and gas in the tissue plane
- Caused by C. perfringens type C strains, producingβ toxin
• Necrotizing enterocolitis: associated with C. perfringens type A
• Gangrenous appendicitis.
Other Clostridial Infections
• Bacteremia: C. perfringens followed by C. tertium and C.septicum
• Skin and soft-tissue infections: C. perfringens, C.histolyticum, C.
septicum, C. novyi, and C. sordellii
• Endometritis leading to toxic shock - C. sordellii
• Meningitis and brain abscess
• Panophthalmitis (due to C. sordellii or C. perfringens).
Gas Gangrene
• Rapidly spreading, edematous myonecrosis, in association with
severely crushed wounds contaminated with pathogenic clostridia,
particularly with C. Perfringens
• Etiological agents - always polymicrobial
- Established agents: C. perfringens (60%) & C.novyi and C.septicum
(20–40%)
- Probable agents: less commonly implicated —C.histolyticum,
C.sporogenes, C.fallax, C.bifermentans, C.sordellii, C.aerofoetidum and
C.tertium.
Pathogenesis
• Anaerobic environment: Crushing injuries of muscles, open fractures
of long bone, foreign bodies, devitalized tissues  interruption in the
blood supply  tissue ischemia
• Contamination of wound with clostridial spores present in the soil
(during war or road traffic accident) or clothes
• Non-traumatic gas gangrene - rare via hematogenous seeding of
normal muscle with bowel clostridia (e.g. colonic malignancy).
Virulence Factors Mediating Gas
Gangrene
• Toxins produced by C. Perfringens
• α toxin - phospholipase C and sphingomyelinase activities 
aggregates of platelets and neutrophils in the bloodvessels causing
occlusion
• α toxin directly suppresses myocardial contractility  reduction in the
cardiac output hypotension
• θ toxin - marked vasodilation by activating mediators (e.g.
prostacyclin, platelet-activating factor).
Gas gangrene
Clinical Manifestation of Gas
Gangrene
• incubation period- 10 hrs to 7 days, depending upon nature
of injury, amount of wound contamination and type of
clostridial species involved
• Clinical manifestations: Mortality rate (50%)
- Excruciating local pain , sudden
- foul-smelling thin serosanguineous discharge
- Gas bubbles (crepitus) in muscle planes
- Brawny edema and induration gangrene & liquefication
- Shock and organ failure
Laboratory Diagnosis of Gas
Gangrene
• Treatment to be started early Based on the clinical diagnosis.
Laboratory diagnosis has role only for Confirmation of the clinical
diagnosis & Species identification
• Specimen
- Ideal samples - Necrotic tissues, muscle fragments and exudates from
deeper part of the wound
- Blood culture if bacteremia is suspected
- Swabs rubbed over the wound surface or soaked in exudates are not
satisfactory
• Transport immediately in Robertson’s cooked meat broth
 Direct Microscopy
• Absence of neutrophils characteristic feature
• Thick, stubby, boxcar-shaped, gram-positive
bacilli without spore— C. perfringens
• Spore bearing gram-positive bacilli suggest
other clostridia
• Citron bodies - C.septicum
• Large rods with oval sub-terminal spores— C.
novyi.
 Target hemolysis
• Double zone hemolysis
• Blood agar - inner narrow zone
of complete hemolysis (due to θ
toxin), surrounded by a much
wider zone of incomplete
hemolysis (due to the alpha
toxin)
 Nagler’s reaction
• Lecithinase activity of α toxin
• Opalescence surrounding streak line
on egg yolk agar or media containing
20% human serum
• Opalescence inhibited by anti-α
toxin if added in medium
• Positive – C.perfringens, C.
Bifermentans,C. baratti and C.
sordellii
 Reverse CAMP test
• C.perfringens is streaked over the center of
blood agar plate and Streptococcus agalactiae is
streaked perpendicular to it
• Presence of enhanced zone of hemolysis
(arrow-shaped) pointing towards C.perfringens
indicates the test is positive
 Other tests
• Heat tolerance: • litmus milk- C.perfringens
• C. perfringens can grow when produces “stormy clot reaction”
RCM broth is incubated at 45°C due to fermentation of lactose
for 4–6 hours. This differentiates producing acid and vigorous gas
it from other organisms in the
specimen
Treatment Gas gangrene
• Early surgical debridement is the most crucial step - All devitalized
tissues widely resected. Closure of wounds delayedfor 5–6 days until
the sites are free from infection
• Antibiotics: Combination of penicillin and clindamycin is
recommended for 10–14 days
• Hyperbaric oxygen: may kill the obligate anaerobic clostridia such as
C. perfringens; Has no effect onaerotolerant clostridia (C. septicum)
• Passive immunization with anti-α-toxin antiserum.
CLOSTRIDIUM TETANI
CLOSTRIDIUM TETANI
• Obligate anaerobic, gram-positive bacillus with terminal round spore
(drum stick appearance)
• Causes ‘tetanus’—skeletal muscle spasm and autonomic nervous
system disturbance
• C. tetani is ubiquitous in nature, widely distributed in soil, hospital
environment and intestine of man and animals.
Virulence Factors
• Tetanolysin: Heat labile, oxygen labile hemolysin. No role in
pathogenesis of tetanus
• Tetanospasmin (or tetanus toxin): neurotoxin responsible for
tetanus
- Prevents the presynaptic release of inhibitory neurotransmitters
glycine and GABA, which leads to spastic muscle contraction
- Antigenic. Toxoided by formaldehyde
- Plasmid coded
Mode of Transmission
• Tetanus bacilli enter through:
- Injury (superficial abrasions, punctured wounds, road traffic
accidents)
- Surgery done without proper asepsis
- Neonates: Following abortion/delivery, due to unhygienic practices
- Otitis media (otogenic tetanus)
- Noninfectious: There is no person-to-person spread
Clinical Manifestations
• Incubation period - 6–10 days. Shorter the incubation period, graver is
the prognosis. Muscles of the
- Face and jaw are often affected first
- First symptom: Trismus or lock jaw,  muscle pain and stiffness, back
pain, and difficulty in swallowing
- Neonates - difficulty in feeding
Clinical Manifestations
• Painful muscle spasm -
- Localized: Involves the affected limb
- Generalized painful muscle spasm → leads to descending spastic
paralysis
• Autonomic disturbance - low or high blood pressure, tachycardia,
intestinal stasis, sweating, increased tracheal secretions and acute
renal failure.
 Complications
• Risus sardonicus: abnormal,
sustained spasm of the facial
muscles that appears to produce
grinning
 Complications
• Opisthotonos position:
abnormal posture of the body,
occurs due to generalized spastic
contraction of the extensor
muscles
• Respiratory muscles spasm
Neonatal Tetanus
• Neonatal tetanus (WHO definition) - ‘an illness occurring in a child
who loses ability to suck and cry between day 3 and 28 of life and
becomes rigid and has spasms’
• Also known as“8th day disease” as the symptoms usually start after
1 week of birth
• Most common reason: Unhygienic practices during deliveries such as
infected umbilical stumps due to application of cow dung, rarely by
circumcision or by ear-piercing
• Seasonal: More common in July, August and September months
Neonatal tetanus
Epidemiology
• Tetanus is more common in developing countries including India due
to:
- Warm climate
- Rural area with fertile soil
- Unhygienic surgeries or deliveries.
• Incidence decreasing due to widespread immunization of infants and
pregnant mothers
 Laboratory Diagnosis
• Treatment started immediately based on
clinical diagnosis. Laboratory diagnosis –
only supportive
• Specimen
• Excised tissue bits from the necrotic
depths of wounds
• Gram Staining
- Gram-positive bacilli with terminal and
round spores (drum stick appearance)
Culture
• Culture is more reliable than microscopy
• Robertson cooked meat broth: C. tetani, being proteolytic turns the
meat particles black and produces foul odor
• Blood agar with polymyxin B: These plates are incubated at 37°C for
24–48 hours under anaerobic condition.
• C. tetani produces characteristic swarming growth
Toxigenicity Test
• In vitro hemolysis inhibition test: indicates the production of only
tetanolysin but not tetanospasmin
• In vivo mouse inoculation test: growth suspension injected in root of
tail of mouse. Animal develops stiffness which begins with the tail
and progresses to involve the hind limbs on the inoculated side → the
other limb → trunk →forelimbs.
• Death within two days. This test indicates the production of
tetanospasmin.
Treatment Tetanus
• Passive immunization (tetanus immunoglobulin) - Treatment of
choice
1. HTIG (Human tetanus immunoglobulin)
2. ATS (Antitetanus serum, equine derived).
• Dosage: 250 IU of HTIG or 1500 IU of ATS single IM
• Duration of protection: Effect of HTIG and ATS last for 30 days and 7–
10 days respectively
Treatment
• Combined Immunization (Both active and passive
immunization) - in nonvaccinated person
• Antibiotics: Minor role as they cannot neutralize the toxins
• ‰They are useful:
- Early infection, before expression of the toxin (<6 hours)
- To prevent further release of toxin
- Metronidazole - drug of choice. (400 mg rectally or 500 mg IV
every 6 hourly for 7 days)
- Penicillin - alternatively
Other measures:
• Symptomatic treatment: Antispasmodic (benzodiazepines)can be
given
• Entry wound should be identified, cleaned and debrided of necrotic
material, so as to remove the anaerobic foci of infection
• Patient should be isolated in a separate room as any noxious stimulus
can aggravate the spasm
Prevention
• Active Immunization (Vaccine) - most effective
• Tetanus toxoid (TT)
- Monovalent vaccine:
- Plain formal toxoid (or fluid toxoid): prepared by exposing to formalin
- Adsorbed: Formol toxoid is adsorbed on to alum
- Combined vaccine: DPT (Diphtheria toxoid, Pertussis whole cell killed
preparation and Tetanus toxoid)
Prevention
• Primary immunization of children: Tetanus toxoid
• 3 doses of Pentavelent vaccine (DPT, Hib HBV) at 6, 10 and 14 weeks
of birth  2 booster doses of DPT at 16–24 weeks and 5 years  two
additional doses of TT at 10 years and 16 years
• Adult immunization: If primary immunization is not administered in
childhood- Four doses of TT; 2 doses at 1 month interval  2 booster
doses at 1 year and 6 years
• Site: deep intramuscular route at anterolateral aspect of thigh
(children) and in deltoid (adults)
• Protective titer: antitoxin titre is ≥0.01 unit/mL.
 Prevention of Tetanus after
Injury
• Surgical toilet immunization which depends on the wound
type and immunization status of the individual
Type Major Toxin produced Disease
A Alpha Gas gangrene,
Food poisoning
B Alpha, beta and epsilon Lamb dysentery

C Alpha and beta Enteritis necroticans in humans

D Alpha and epsilon Enterotoxemia and pulpy kidney
disease in sheep
Prevention of Neonatal Tetanus
• Promoting hospital or attended deliveries
- Aseptic clean practices are followed during deliveries—clean
hand, clean surface, clean blade for cutting cord, clean cord tie,
clean cord stump, cleantowel and clean water
• TT (2 doses) - to all pregnant women
• Neonatal tetanus elimination is based on:
- Neonatal tetanus rate: 1/1000 live births in every district
- TT coverage to pregnant women >90%
- Attended deliveries >75%
CLOSTRIDIUM BOTULINUM
CLOSTRIDIUM BOTULINUM
• Clostridium botulinum produces botulinum toxin and causes botulism
• Latin word botulus - sausage (as poorly cooked sausages were
formerly associated with food poisoning)
• Anaerobic Gram-positive Bacillus with subterminal spore
• Ubiquitous in nature, saprophyte in soil, animal manure, vegetables
and sea mud
Pathogenesis- Botulinum toxin
• Non-invasive
• Pathogenesis is due to production of powerful neurotoxin ‘botulinum
toxin’ (BT)
• Serotype: Eight serotypes—A, B, C1, C2, D, E, F and G
• Serotypes A, B, E commonly cause human disease; most severe being
serotype A
• All serotypes produce neurotoxin; except C2 which produces an
enterotoxin
• BT types C and D are bacteriophage coded
Pathogenesis- Botulinum toxin
• Produced intracellularly, not secreted and appears outside only after
autolysis of bacterial cell
• Synthesized initially as a nontoxic protoxin  trypsin or other
proteolytic enzymes convert it into active form
• Mechanism of Action of Botulinum Toxin (BT)
Entry (ingested, inhaled, from wound)  via blood to peripheral
cholinergic nerve terminals (neuromuscular junctions, postganglionic
parasympathetic nerve endings, and peripheral ganglia) bind to Ach
receptors at neuromuscular junction blockage of release of Ach 
Flaccid paralysis
Botulinum toxin
• Also produced by C. butyricum , C. baratti and C. argentinense
• Recovery: Blocking of Ach receptor is permanent, but the action is
short lasting as the recovery occurs in 2–4 months, once the new
terminal axons sprout
• Spores do not produce toxins. Toxin production requires spore
germination, which occurs in anaerobic atmosphere
• Spores do not normally germinate in adult intestine, however may
germinate in the intestine of infants
• Therapeutic uses: Spasmodic conditions such as strabismus,
blepharospasm and myoclonus
Clinical Manifestations
• Diplopia, dysphasia, dysarthria
• Descending symmetric flaccid paralysis of voluntary muscles
• Decreased Deep tendon reflexes
• Constipation
• Respiratory muscle paralysis, may lead to death
• No sensory or cognitive deficits
Types of Botulism
• Food-borne botulism: foods contaminated with preformed botulinum
toxin
- Most common source: Homemade canned food
- Mostly sporadic; outbreaks are rare
• Wound botulism: Contamination of wounds with C. botulinum spores
- Presents like foodborne botulism except for absence of
gastrointestinal features
Types of Botulism
• Infant botulism:
- Ingestion of contaminated food with spores of C. botulinum in children ≤1
year of age
- Manifestations - inability to suck and swallow, weakened voice, ptosis, floppy
neck, and extreme weakness (floppy child syndrome)
-Self-limiting  Rarely generalized flaccidity, respiratory failure and sudden
death. - Management - supportive care
• Adult intestinal botulism: suppressed normal flora, colonized clostridial
spores may germinate producing toxin
• Iatrogenic botulism: injection of overdose of the toxin while used for
therapeutic purpose
Laboratory Diagnosis
• Microscopy of Food/feces
- Gram-positive, non-capsulated bacilli with subterminal, oval,
bulging spores
- Motile by peritrichate flagella
• Isolation:
• RCM broth: Turbidity occurs with meat particles turning:
- Black and production of foul odor: C. botulinum A, B, F
(proteolytic)
- Pink: C. botulinum C, D, E (saccharolytic).
• Blood agar: Irregular, hemolytic with fimbriated border
Toxin Demonstration (Mouse
Bioassay)
• Mere presence of bacilli in food or feces is of less significance. Toxin
demonstration is more meaningful
• Specimens - serum, stool, sterile water or saline enema, gastric
aspirates, wound material or foods samples
• Specimens injected into mouse  paralysis in 48 hours; which can be
inhibited by prior administration of specific antitoxin
Treatment of Clostridium
botulinum
• Meticulous intensive care support
• Botulinum antitoxin: Administered immediately on clinical suspicion,
without waiting for laboratory confirmation. However, once toxin
binds to nerve endings, antitoxin has no role
• Wound botulism - debrided and drained promptly
• Antibiotics: Susceptible to penicillin; role of antibiotics has not been
established.
CLOSTRIDIOIDES DIFFICILE
CLOSTRIDIOIDES DIFFICILE
• Obligate anaerobic, Gram-positive, spore-forming Bacillus
• Responsible for pseudomembranous colitis - in association with
prolonged antimicrobial use
• Named due to unusual difficulties in isolation of C.difficile.
• Taxonomically, it is recently placed into a separate genera,
Clostridioides difficile
Pathogenesis
• Major cause of hospital-acquired infection mainly in the
Western world
• Risk factors:
• Prolonged hospital stay: Spores in hospital environment
colonize colon of patients
• Prolonged antimicrobial use: Disruption of normal colonic
flora  enhances C. difficile infection
- Cephalosporins (e.g. Ceftriaxone) – More common
- Others - Clindamycin, Ampicillin and fluoroquinolones„
Toxin production
• Only toxigenic strains are pathogenic
• Two powerful exotoxins—toxin A (enterotoxin) & toxin B
(cytotoxin)
- Both toxins secreted in intestine → glycosylate GTP binding
proteins that regulate the cellular actin cytoskeleton →
disruption of the cytoskeleton  loss of cell shape,
adherence, and disruption of epithelial cell barrier →
diarrhea & pseudomembrane formation
• Infants - asymptomatic infection as they lack suitable
mucosal toxin receptors
 Toxin production
• Host immune response determine the outcome
- Strong IgG response to toxin A— become asymptomatic carriers
- Inadequate IgG response to toxin A— develop disease
• Other risk factors:
- Suppression of normal flora, Advanced age (>65 years)
- Immunosuppression & malignancy, Gastric acid suppressant
medications, Use of electronic rectal thermometer
- Hypervirulent epidemic strain: BI/NAP1/027 - produces higher
levels of toxins and causes severe infection
 Clinical Manifestations
• Diarrhea – MC manifestation
- Others - abdominal pain and leukocytosis, Blood in stool rare
• Pseudomembrane:
- Composition: necrotic leukocytes, fibrin, mucus & cellular debris
- Attaches to the underlying mucosa
- whitish-yellow plaque , 1–2 mm to large enough to spread over
the entire colonic mucosa
• Relapse after treatment - 15–30% of cases.
Laboratory Diagnosis
• Isolation:
• Stool culture: Anaerobic culture on selective
- CCFA (cefoxitin cycloserine fructose agar)
- CCYA (cefoxitin cycloserine egg yolk agar)
- Sensitive and specific
- Since C.difficile can be a GIT colonizer the GIT, only isolation is not
enough to establish the infection. Toxin demonstration is more
meaningful
Laboratory Diagnosis
• Cell culture cytotoxin neutralization assay: Highly specific but not
very sensitive & has long turnaround time
• Toxin detection:
• Toxin and Glutamate dehydrogenase (GDH) detection: GDH is
common antigen present in both toxigenic and non-toxigenic strains
• Enzyme immunoassay or rapid tests
 Laboratory Diagnosis
A. All negative: Rules out
presence of C. difficile in stool
B. Positive for GDH only: Confirms A B C
presence of nontoxigenic strain
of C.Difficile
C. Positive for toxin A and GDH:
Confirms C. Difficile expressing
either toxin A or toxin B„
 Laboratory Diagnosis
• Molecular methods: PCR, real time
PCR, gene Xpert targeting gene coding
for C. Difficile toxins in stool
• Colonoscopy: It is highly specific if
pseudomembranes sensitivity is low
• Histopathology: highly specific but
sensitivity is very
Treatment Clostridium difficile
• Antimicrobial therapy:
• Initial episode, mild to moderate cases: Oral metronidazole (500 mg
TID 10–14 days)
• Recurrent episodes or severe cases: Vancomycin (500 mg, QID 10–14
days)
• Severe complicated or fulminant infection: Vancomycin (via
nasogastric tube and by retention enema) plus IV metronidazole
Treatment Clostridium difficile
• Other modalities of treatment:
• Intravenous Immunoglobulin: Passively provide antibodies to
neutralize the C. difficile toxins, primarily toxin A
• Fecal transplant: It involves replenishing of the gut flora with donated
feces from a screened healthy donor
• Fidaxomicin: It is a macrolide antibiotic, can be used in cases of
relapse and also against hypervirulent strains
Prevention (Infection Control
Measures)
• Broad spectrum antimicrobials should be stopped at the earliest.
• Infection control measures of contact precaution:
- Strict hand hygiene with chlorhexidine 4% hand wash
- Isolation of patient
- Ensure proper disinfection of floor, surfaces, toilets and other soiled
areas using 1% freshly prepared hypochlorite solution
CLINICAL PRESENTATION OF
ANAEROBIC INFECTIONS
• Infections adjacent to mucosal surfaces that bear anaerobic
flora
• Predisposing factors:
- Ischemia, Tumor
- Penetrating trauma, foreign body, or perforated viscus
• Spreading gangrene involving skin, subcutaneous tissue,
fascia, and muscle
• Foul smelling putrid pus
• Abscess formation
CLINICAL PRESENTATION OF
ANAEROBIC INFECTIONS
• Septic thrombophlebitis
• Toxemia and fever not marked
• Failure to respond to antibiotics not with anaerobic activity
• Organisms seen in Gram stain, fail to grow in routine aerobic
culture
• Special features: Gas in specimen (gas gangrene)
- Black pigment that fluoresce (P. Melaninogenica)
- Sulfur granules (Actinomyces).
LABORATORY DIAGNOSIS
• Specimens
• All clinical specimens must be handled meticulously as brief exposure
to oxygen may kill obligate anaerobes and result in failure to isolate
them in the laboratory.
• Accepted specimens: Tissue bits, necrotic materials,aspirated body
fluids or pus in syringes
• Unacceptable specimens: All swabs, sputum or voided urine
• Immediately put into RCM broth or other anaerobic transport media
and brought to the laboratory as soon as possible
 LABORATORY DIAGNOSIS
• Microscopy
• All clinical specimens from
suspected anaerobic
infections should be Gram
stained and examined for
characteristic morphology
LABORATORY DIAGNOSIS
• Culture under anaerobiosis on :
- Anaerobic blood agar, Neomycin blood agar
- Egg yolk agar, Phenylethyl agar (PEA)
- BHIS agar: Brain–heart infusion agar added with supplements, such as
vitamin K and hemin
- Bacteroides bile esculin agar (BBE agar).
• Identification of anaerobes is based on:
- Biochemical tests
- Susceptibility to antibiotic disks
- Gas liquid chromatography.
Treatment Anaerobic infections
• Common antibiotics used:
- Metronidazole
- Carbapenems (imipenem)
- β-lactam/β-lactamase inhibitor combination (ampicillin/sulbactam)
- Chloramphenicol
• Choice of antibiotics depends on the site of infection, type of
anaerobe involved and susceptibility to antibiotics
• Antimicrobial resistance in anaerobic bacteria is an increasing
problem.